Travelling home for treatment and EU patients’ rights to care abroad: Results of a survey among German students at Maastricht University

Abstract

Empirical evidence on patient mobility in Europe is lacking despite widespread legal, policy and media attention which the phenomenon attracts. This paper presents quantitative data on the health care seeking behaviour of German students at Maastricht University in the Netherlands. A cross-sectional survey design was applied with a mixed-methods approach including open and closed questions. Questionnaire items were based on a theoretical model of patient mobility and input from focus group discussions with German students living in Maastricht. 235 valid surveys were completed, representing ca. 8% of the target population. Data collection took place in Oct–Dec 2010.

Of respondents who received medical care over the last two years, 97% returned to Germany; of these, 76% travelled to their home city for medical treatment. 72% received care only in Germany, i.e. not even once in Maastricht. Distance partly influenced whether students travelled to Germany, returned home or stayed in Maastricht, and the type of care accessed. Key motivations were familiarity with home providers/system, and reimbursement issues.

In the context of the new EU Directive on patients’ rights, the findings call into question whether Europeans use entitlements to cross-border care and what the real potential of patient mobility is. The results demonstrate the existence and magnitude of return movements as a sub-group of patient mobility.

Introduction

After more than a decade of ECJ jurisprudence on patient mobility and almost three years of negotiations between Member States, the European Commission and the European Parliament, the Directive on the application of patients’ rights in cross-border health care was adopted in early March 2011 [1]. The Directive clarifies the obligations of Member States and the entitlements of EU citizens in terms of access to cross-border care. Given the intense efforts and attention devoted to patient mobility (see e.g. [2]), surprisingly little evidence exists on the extent to which Europeans use their right to receive treatment abroad.

EU citizens may access planned health care services outside their Member State of affiliation under certain conditions. For most types of services, the Directive and the pre-existing Regulation 883/2004 stipulate that prior authorisation by the competent authority is necessary for medical expenses to be covered by the patient's country. Yet, this requirement can be loosened e.g. when cross-border agreements or contracts exist between payers and providers in different Member States or based on EU legislation according to which certain population groups enjoy ‘double cover’ – they may receive health care in the country where affiliated and in the country where they work, study, and/or reside [3]. One such group are EU students who pursue their studies in another Member State. Europeans with facilitated access to planned care abroad are interesting from a patient mobility research perspective as they provide testing ground for understanding whether EU citizens make use of their right to be treated in another Member State.

The aim of this article is twofold. The first is to gather evidence on whether Europeans use their entitlements to cross-border care by examining a specific population group with double cover. The research setting is that of Maastricht University, the Netherlands, situated close to the German border and counting thousands of German students. Informal discussions suggested that many if not most return to Germany for health care despite having to travel long distances. This observation led to the setting up of a survey to quantify movements, identify their directions and empirically test a series of assumptions derived from earlier research on motivations influencing patient mobility in general and return movements in particular. The survey was designed to investigate the extent to which (1) German students return to Germany for health care; (2) German students return to their home city for health care; (3) German students receive health care in Maastricht; (4) distance affects health care utilisation and (5) familiarity as a motivation determines health care seeking behaviour.

The second objective is to broaden our understanding of patient mobility. Patient mobility is commonly seen as patients going to a foreign country for treatment. Less attention is paid to those travelling home. Studies however show that patients travel to their home country for care, e.g. across the USA-Mexico border where such flows are significant in both directions [4], [5], [6], [7], [8], [9], and in Europe where British pensioners in Spain return to the UK for treatment [10], [11]. The issue of which EU Member State should pay for returning pensioners became contentious during negotiations over the patients’ rights Directive [12] and there is good reason to believe that return flows will gain importance in an increasingly mobile Europe and globalised world. These flows represent patient mobility in reverse: as they travel home for treatment, returners exit an unfamiliar health system to enter the one they are familiar with. Understanding return flows may thus be revealing for how we conceptualise patient mobility.

This article presents empirical data on the cross-border health care seeking behaviour of a specific group of Europeans and discusses the implications for how we perceive patient mobility – conceptually as well as in the context of the new Directive.